A systematic review and meta-analysis of the safety and efficacy of endoscopic enucleation and non-enucleation procedures for benign prostatic enlargement

Abstract

Introduction and objective

This study aims to evaluate safety and efficacy of different endoscopic enucleation of the prostate (EEP) techniques, by comparing laser (L-EEP) and non-laser (NL-EEP) procedures; and EEP versus other endoscopic non-enucleation (ENE) surgeries for benign prostatic enlargement (BPE).

Methods

A systematic literature review was performed for randomized clinical trials (RCT) that compared different endoscopic treatments for BPE, between 1982 and 2018. Two analyses were performed: (1) EEP versus ENE; and (2) L-EEP versus NL-EEP. Efficacy was assessed using perioperative data (removed tissue volume, operation time (OT), catheterization time, length of hospital stay); and functional outcomes [IPSS, IIEF-5, maximum flow rate (Qmax), postvoid residual volume (PVR), quality of life (QoL)]. Safety was assessed through complications (Hb and sodium decrease, transfusion rate). Meta-analyses were performed using RevMan® 5.3.

Results

Out of 35 RCTs (4066 patients), 31 (3909 patients) evaluated EEP versus ENE, and 4 (327 patients) evaluated L-EEP versus NL-EEP. EEP presented greater Qmax. Also, EEP presented less catheterization time, length of hospital stay, Hb decrease, transfusion rate. OT and bladder injury were greater with EEP. There were no significant differences between other items. L-EEP removed more tissue volume, with a smaller drop in serum Hb. There were no significant differences in other perioperative data, functional outcomes, complications.

Conclusions

EEP and ENE are effective and safe for treating BPE. Perioperative data favors EEP. Statistical differences, with questionable clinical significance in functional outcomes and complication rates were encountered. L-EEP provides greater tissue removal and smaller Hb decrease then NL-EEP, with similar functional profiles.

Introduction

Benign prostatic enlargement (BPE) is the most common benign neoplasm in men and affects more than 50% of men over 60 years old [1]. Almost 30% of patients with lower urinary tract symptoms (LUTS) due to BPE need treatment, and about 20% are refractory to clinical treatment and therefore undergo surgery. Several surgical techniques are available to treat BPE [2]. Recent technological developments aim to maintain excellent functional outcomes while reducing the morbidity associated with the procedure.

Endoscopic enucleation of the prostate (EEP) [3] is a minimally invasive procedure that can be used on prostates of any volume and can be performed through different energy sources [4]. EEP supposedly provides excellent durable functional results and lower comorbidity rates. Nevertheless, it is still underperformed worldwide [5]. The aim of this systematic review and meta-analysis is to evaluate the efficacy and safety of EEP options versus other endoscopic procedures that do not enucleate the prostate (ENE). Furthermore, in the EEP group, techniques that use laser as the energy source (L-EEP) were compared to techniques that do not use lasers (NL-EEP).

Methods

Literature search and inclusion of studies

This study was conducted following the PRISMA criteria and registered on and approved by PROSPERO (CRD42018099714). A systematic review was conducted to identify randomized clinical trials (RCTs) published in English from 1982 to December 2018 on the Pubmed, Embase, and Cochrane databases. Two authors participated in the literature search (SBT and PPK), and three participated in the data acquisition process (SBT, PPK, and BSA). The following keywords were used in the databases: MEP OR MTUEP OR MTUERP OR BEP OR BTUEP OR BTUERP OR TUEB OR THULEP OR TUERP OR TUEP OR HOLEP OR GREENLEP OR GLEP OR PKEP OR DILEP OR ELEP OR MONOPOLAR OR BIPOLAR OR THULIUM OR HOLMIUM OR GREENLIGHT OR PLASMAKINETIC OR PLASMA KINETIC OR DIODE OR ERASER AND ENUCLEATION AND PROSTATE OR SIMPLE PROSTATECTOMY.

After the exclusion of duplicate studies and congress abstracts, the first selection was done based on papers’ titles and abstracts (SBT and PPK). Articles were included if they compared endoscopic treatment techniques that reported perioperative data, functional outcomes, or complication rates. Once selected, the full text of the articles was studied to gather information about the study design and inclusion criteria. The evaluation of treatment efficacy included perioperative parameters (surgical time, removed tissue weight, catheterization time, length of hospital stay) and functional outcomes (international prostate symptom score [IPSS], international index of erectile function [IIEF], maximum flow rate [Qmax], quality of life [QoL], and post voiding residual volume [PVR]). These findings were divided into the following postoperative periods: immediate (1 month), short term (3–6 months), medium term (12–18 months), and long term (≥ 24 months). Treatment safety was evaluated according to the decrease in hemoglobin (Hb) and sodium (Na), hemotransfusion rate, bladder injury, acute urinary retention, re-catheterization, urinary tract infection, transient incontinence, urethral stenosis, re-operation rates, and transurethral resection syndrome (TURS) divided into immediate (1 month), short term (until 12 months) and long term (> 12 months).

The methodological quality of the RCTs was analyzed using the Jadad composite scale [6]. Two reviewers (JDC and MLW) independently allocated quality scores to the identified studies. Disagreements were resolved by consensus.

Group allocation

To compare enucleation to non-enucleation endoscopic surgeries, the surgical techniques were grouped according to the main procedure that was performed. Therefore, the group of ENE procedures included monopolar and bipolar transurethral resection of the prostate (M and BTURP), plasmakinetic resection of the prostate (PKRP), transurethral vaporization in saline (TUVis), and photovaporization of the prostate (PVP). The EEP group included holmium laser enucleation of the prostate (HoLEP), thulium laser enucleation of the prostate (ThuLEP), diode laser enucleation of the prostate (DiLEP), eraser laser enucleation of the prostate (ELEP), plasmakinetic enucleation of the prostate (PKEP), plasma kinetic enucleo-resection of the prostate (PKERP) photovaporization and enucleation of the prostate (PVEP), bipolar transurethral enucleation of the prostate (BTUEP) and monopolar transurethral enucleo-resection of the prostate (MTUERP). The L-EEP group consisted of HoLEP, ThuLEP, DiLEP, and ELEP, while the NL-EEP group included PKEP, PKERP, BTUEP, and MTUERP techniques.

Statistical analysis

Data were independently extracted from each report by three authors (SBT, PPK, and BSA) using a data record developed for this purpose. After extraction, the data were reviewed by the first author. Instances of disagreement between the extractors were resolved by reaching consensus among researchers.

A meta-analysis was considered for each outcome including perioperative data, efficacy, or complications for every head-to-head comparison. The meta-analysis was conducted using RevMan® software v.5.3 (Cochrane Collaboration, Oxford, UK). Statistical heterogeneity was tested using the I2 test. The results were expressed as the weighted mean difference with the 95% confidence interval (CI) for continuous outcomes and as the odds ratio (OR) with a 95% CI for dichotomous variables. A meta-analysis of continuous variables was possible only for studies reporting them as means and standard deviations.

Results

Characteristics of eligible studies

The initial database search yielded 359 records. After the removal of duplicates, 239 articles were considered. Articles were excluded if they were duplicates (n = 23), clinical trials registry (n = 13), editorials or comments (n = 6), meeting abstracts (n = 72), non-randomized studies (n = 19), articles in other languages (n = 5), irrelevant topics (n = 31), reviews (n = 9), and articles updated in more recent publications (n = 6). A total of 59 articles were considered for full text review. Two articles were eliminated because they were not RCTs, nine were updated in recent publications, and 13 did not compare endoscopic techniques. Figure 1 shows the flow diagram. Thirty-five studies were selected for the meta-analysis. Among the enrolled studies, 31 papers (3909 patients) compared endoscopic techniques to treat BPE (EEP vs. ENE), and 4 articles (327 patients) compared L-EEP and NL-EEP. Table 1 shows the studies’ characteristics and patients’ baseline parameters.

Fig. 1
figure1

Flow diagram

Table 1 Selected studies

Outcomes of efficacy variables in EEP vs. ENE

IPSS

IPSS data were obtained from 25 trials [7,8,9,10,11,12,13,14,15,16,17,18,19,20,21,22,23,24,25,26,27,28,29,30,31]. There were 18 trials that reported IPSS at 1 month [7, 8, 10,11,12,13, 15, 16, 19,20,21,22, 24,25,26,27, 30, 31], 21 trials reporting it at 3–6 months [7,8,9,10,11,12, 14,15,16, 18,19,20,21,22,23,24, 26, 27, 29,30,31], 16 trials reporting it at 12–18 months [7, 8, 10,11,12,13, 15, 16, 19,20,21, 24, 25, 27, 30, 31], and nine trials reporting it over 24 months [7, 10, 16, 17, 20, 27, 28, 30, 31]. EEP presented a better IPSS than non-enucleation techniques in the postoperative period of 12–18 months (− 0.86, 95% CI [− 1.44, − 0.29], p < 0.05, I2 = 92%). However, there were no significant differences in IPSS during 1 month, 3–6 months, and > 24 months post-operation (Fig. 2).

Fig. 2
figure2figure2

IPSS. a At 1 month; b at 3–6 months; c at 12–18 months; d over 24 months

Qmax

Qmax data were acquired from 25 trials [7, 9,10,11,12,13,14,15,16,17,18,19,20,21,22,23,24,25,26,27,28, 30,31,32,33]. Seventeen studies reported Qmax at the first postoperative month [7, 10,11,12,13, 15, 16, 19,20,21,22, 24,25,26,27, 30, 31], 21 reported it at 3–6 months [7, 9,10,11,12, 14,15,16, 18,19,20,21,22,23,24, 26, 27, 30,31,32,33], 17 reported it at 12–18 months [7, 10,11,12,13, 15, 16, 18,19,20,21, 24, 25, 27, 28, 30, 31], and 10 reported it over 24 months [7, 10, 16, 17, 20, 21, 27, 28, 30, 31]. There was a significant benefit of EEP in terms of Qmax in the immediate (1.06 ml/s, 95% CI [0.26, 1.87], p < 0.05, I2 = 87%), short-term (1.00 ml/s, 95% CI [0.3, 1.7], p < 0.05, I2 = 81%), and long-term (1.77 ml/s, 95% CI [1.71, 1.84], p < 0.05, I2 = 68%) follow-up periods (Fig. 3).

Fig. 3
figure3figure3

QMAX. a At 1 month; b at 3–6 months; c at 12–18 months; d over 24 months

IIEF

IIEF scores comparing EEP and non-enucleation techniques were obtained from six trials [10, 17, 20, 30, 31, 33]. There were no significant differences according to a pooled analysis of IIEF scores at 1 month, 3–6 months, 12–18 months, and 2 years or more post-operation (Fig. 4).

Fig. 4
figure4

IEFF. a At 1 month; b at 3–6 months; c at 12–18 months; d over 24 months

PVR

PVR data were obtained from 16 trials [7, 8, 10,11,12, 14, 15, 19, 20, 22, 23, 25,26,27,28, 30]. Ten trials reported PVR at 1 month [7, 8, 11, 12, 15, 19, 20, 22, 26, 30], 15 reported it at 3–6 months [7,8,9,10,11,12, 14, 15, 19, 20, 22, 23, 26, 27, 30], eight reported it at 12–18 months [7, 11, 12, 15, 19, 20, 25, 30], and four reported it at 2 years or more [7, 20, 28, 30]. EEP had a lower PVR than ENE techniques during the short- and medium-term follow-up periods (− 6.00 ml, 95% CI [− 8.30, − 3.69], p < 0.05, I2 = 87%; − 9.57 ml, 95% CI [− 14.98, − 4.15], p < 0.05, I2 = 93%). However, there were no significant differences in PVR in either the immediate-term or in the long-term follow-up periods (Fig. 5).

Fig. 5
figure5figure5

PVR. a At 1 month; b at 3–6 months; c at 12–18 months; d over 24 months

QoL

QoL data were obtained from 15 trials [8, 10, 11, 15,16,17, 21, 22, 24,25,26,27,28,29,30]. Twelve trials reported QoL at 1 month [8, 10, 11, 15, 16, 21, 22, 24,25,26,27, 30], 12 reported it at 3–6 months [8, 10, 11, 15, 16, 21, 22, 24, 26, 27, 29, 30], 11 reported it at 12–18 months [8, 10, 11, 15, 16, 21, 24, 25, 27, 28, 30], and seven reported it over 24 months [10, 16, 17, 21, 27, 28, 30]. The pooled analysis showed no significant differences in QoL between EEP and ENE techniques at each follow-up time point (Fig. 6).

Fig. 6
figure6figure6

QoL. a At 1 month; b at 3–6 months; c at 12–18 months; d over 24 months

Perioperative data in EEP vs. ENE (Fig. 7)

Operative time

EEP was associated with longer operative time (12.46 min, 95% CI [5.80, 19.11], p < 0.05, I2 = 96%) in pooled data from 26 studies (3097 patients) [7,8,9,10,11,12,13,14,15,16, 18,19,20,21,22,23,24,25,26, 28,29,30, 34,35,36,37,38].

Fig. 7
figure7figure7

Perioperative data. a Operative time; b resected prostate weight; c catheterization time; d hospital length of stay

Resected prostate weight

There were 21 trials [8,9,10, 12, 14, 16, 18,19,20,21,22,23,24,25,26, 30, 31, 34,35,36, 38, 39] that reported resected prostate weight (2422 patients). The pooled results showed no statistically significant difference between groups (4.66 g, 95% CI [− 1.75, 11.07], p = 0.15, I2 = 98%).

Catheterization time

EEP was associated with a shorter catheterization time (− 0.58 days, 95% CI [− 0.89, − 0.28], p < 0.05, I2 = 98%) in pooled data from 25 studies (2896 patients) [7,8,9,10,11,12, 15, 16, 18,19,20,21,22,23,24,25,26, 28,29,30,31, 34, 36,37,38,39].

Length of hospital stay

EEP was associated with shorter length of hospital stay (− 0.91 days, 95% CI [− 1.22, − 0.60], p < 0.005, I2 = 96%) in pooled data from 20 studies (2599 patients) [8,9,10,11,12, 15, 16, 19,20,21,22, 24,25,26, 28,29,30, 34, 35, 38, 39].

Complications in EEP vs. ENE (Fig. 8)

Immediate

Hb decrease

We extracted data on the decrease of serum Hb from 21 studies (2441 patients) [7,8,9,10, 12, 15, 18,19,20, 22, 24, 26, 28,29,30,31, 34,35,36,37,38,39]. EEP was associated with a smaller drop in serum hemoglobin levels than ENE (− 0.54 mg/dl, 95% CI [− 0.87, − 0.20], p < 0.005, I2 = 98%).

Fig. 8
figure8figure8

Complications. a Hb decrease; b Na decrease; c hemotransfusion rate; d transient incontinence; e bladder injury

Na decrease

There were no statistical differences between EEP and ENE with respect to Na decrease after analyzing 11 studies (1389 patients) [7, 10, 18, 20, 29, 30, 34,35,36,37,38,39] (− 0.35 mEq/L, 95% CI [− 0.76, 0.07], p = 0.1, I2 = 91%).

Hemotransfusion rate

EEP was associated with a lower hemotransfusion rate (OR 0.38, 95% CI [0.21, 0.67], p < 0.005, I2 = 0%) in a pooled data analysis of 19 studies (2288 patients) [7,8,9, 12, 15, 18, 20, 21, 23, 25,26,27, 29,30,31, 34,35,36,37, 39].

Transient incontinence

There were no statistical differences between EEP and ENE with respect to transient incontinence after an analysis of 13 studies (1450 patients) [7, 8, 11, 12, 19,20,21, 23, 24, 26, 29, 30, 34, 37] (OR 1.19, 95% CI [0.71, 2.00], p = 0.5, I2 = 31%).

Bladder injury

We extracted data on bladder injury from 7 studies (817 patients) [7,8,9, 18, 24, 26, 34, 35], and the rate of bladder injury was significantly higher in the EEP group (OR 4.31, 95% CI [1.44, 12.92], p < 0.005, I2 = 0%).

Others

There were no statistical differences between EEP and ENE with respect to urinary tract infection (OR 0.49, 95% CI [0.19, 1.28], p = 0.15) [7, 19, 21, 26, 30, 37], acute urinary retention (OR 0.51, 95% CI [0.15, 1.71], p = 0.27) [7, 8, 24, 26, 34, 35, 37], recatheterization need (OR 0.80, 95% CI [0.38, 1.67], p = 0.55) [7, 18, 20, 21, 23, 26, 27, 36, 37, 39], and TURS (OR 0.24, 95% CI [0.03, 2.20], p = 0.21) [7, 20, 21, 24, 26, 30, 35, 37, 39].

Short-term complications

There were no statistical differences between EEP and ENE with respect to urethral stenosis (OR 0.54, 95% CI [0.25, 1.14], p = 0.1) [7, 8, 12, 18,19,20, 24,25,26, 34,35,36,37], urinary incontinence (OR 0.64, 95% CI [0.10, 4.08], p = 0.63) [8, 24], and reoperation (OR 1.06, 95% CI [0.05, 22.02], p = 0.97) [8, 26, 35, 37, 38].

Long-term complications

There were no statistical differences between EEP and ENE with respect to urethral stenosis (OR 0.86, 95% CI [0.36, 2.08], p = 0.74) [7, 21, 27, 30], bladder neck contracture (OR 1.01, 95% CI [0.34, 3.02], p = 1) [7, 21, 30, 36], and reoperation (OR 0.37, 95% CI [0.08, 1.72], p = 0.2) [7, 27, 30, 36].

Outcomes of efficacy variables in L-EEP vs. NL-EEP

There were no statistical differences between L-EEP and NL-EEP regarding IPSS, Qmax, and PVR at 3–6 months [32, 40, 41]. There was insufficient data to analyze IPSS, Qmax, IIEF, PVR, and QoL during other postoperative periods.

Perioperative data in L-EEP vs. NL-EEP

Operative time

Operative time showed no statistical differences between L-EEP and NL-EEP in pooled data from four studies (327 patients (− 7.07 min 95% CI [− 15.91, 1.77], p < 0.005, I2 = 88%) [32, 33, 40, 41].

Resected prostate weight

Four trials [32, 33, 40, 41] reported the resected prostate weight of 327 patients. The L-EEP group was associated with a greater resected weight than the NL-EEP group (1.83 g, 95% CI [0.23, 3.43], p < 0.05, I2 = 0%).

Catheterization time

There were no statistical differences between L-EEP and NL-EEP with respect to catheterization time after analyzing four studies (327 patients) (− 0.40, 95% CI [− 0.83, 0.02], p = 0.06) [32, 33, 40, 41].

Length of hospital stay

The length of hospital stay showed no statistical differences between L-EEP and NL-EEP in pooled data from four studies (327 patients) (− 0.38 days, 95% CI [− 0.81, 0.05], p = 0.08, I2 = 80%) [32, 33, 40, 41].

Complications in L-EEP vs. NL-EEP

Immediate

Hb decrease

We extracted data on decreases in serum Hb levels from three studies (287 patients) [32, 33, 41]. L-EEP was associated with a smaller drop in serum hemoglobin level than NL-EEP (− 0.32 g/dL, 95% CI [− 0.53, − 0.12], p < 0.05, I2 = 58%).

Others

There were no statistical differences between L-EEP and NL-EEP with respect to Na decrease (− 0.60 mEq/L, 95% CI [− 1.51, 0.31], p = 0.19) [32, 41], transfusion rate (OR 0.36, 95% CI [0.01, 8.88], p = 0.53) [32, 41], urinary infection (OR 0.70, 95% CI [0.11, 4.40], p = 0.7) [32, 40], recatheterization need (OR 1.01, 95% CI [0.35, 2.96], p = 0.98) [32, 33, 40], and transient urinary incontinence (OR 0.77, 95% CI [0.33, 1.82], p = 0.55) [32, 33, 41].

Short term

There were no statistical differences between L-EEP and NL-EEP with respect to urethral strictures (OR 1.39, 95% CI [0.26, 7.61], p = 0.7) [32, 33, 40, 41] and urinary incontinence (OR 0.47, 95% CI [0.04, 5.69], p = 0.56) [40, 41].

Long term

No studies evaluated long-term complications, including strictures, bladder neck contracture, and reoperation.

Discussion

TURP has been considered the standard endoscopic surgery technique for BPH treatment in patients with small and medium-sized prostates. For men with greater gland volumes, open prostatectomy [42] has been the most appropriate option. However, TURP still carries the risk of hemorrhage requiring blood transfusion (2–4.8%) and TURS (0–1.1%) [43], and open prostatectomy is associated with elevated morbidity [44]. Thus, other minimally invasive procedures with excellent functional outcomes and lower complication rates have been adopted more frequently in recent years. Among these new techniques, EEP seems to be the most promising approach since long-term one-arm observational studies demonstrate a lasting improvement in quality of life and functional parameters, as well as a favorable safety profile [16, 17].

A meta-analysis comparing open prostatectomy to HoLEP has already been published [45], which demonstrated that EEP provides equivalent functional results but lower complication rates. For this reason, papers comparing simple prostatectomy to EEP were not evaluated. Another robust meta-analysis compared different endoscopic procedures [46] and head-to-head comparisons of specific technologies, such as HoLEP vs. B-TURP [47], THuLEP vs. TURP [48] have also been published. However, EEP has never been studied as a group and compared to other ENE techniques, despite the technology used to perform the procedure. This grouped analysis is of uttermost importance since EEP is a technically more challenging procedure and many institutions are willing to start performing enucleation surgeries.

In the present meta-analysis, EEP presented significantly better Qmax and IPSS improvements than ENE. Nevertheless, these differences are clinically questionable since the Qmax improvement between groups was 1.0 ml/s in the short term and 1.77 ml/s in the long term. Furthermore, the IPSS was just 0.86 points lower in the EEP group and only in the mid-term follow-up analysis. There was no difference in other functional outcomes and QoL, regardless of the follow-up period that was analyzed.

When comparing perioperative data between EEP and ENE, both presented effective results. However, there was a significant difference favoring EEP in regard to the catheterization time and length of hospital stay, but with longer surgical time. EEP is associated with less bleeding and lower transfusion rate but higher incidence of bladder injury.

It is widely stated that EEP may be associated with a greater risk of transient-stress urinary incontinence. Moreover, since the whole adenoma is removed, one would expect that greater tissue weight would be resected in EEP [10, 12, 16, 19, 20, 24, 25, 30, 31, 35, 36, 38]. Nevertheless, this study did not find any differences in these aspects among groups. This must be due to the fact that NL-EEP patients might have contaminated the enucleation group. This hypothesis is reinforced by the fact that when comparing L-EEP to NL-EEP, the first group had a greater resected weight. No differences were found in the risk of urethral stenosis in both the short and long-term analyses comparing EEP and ENE.

It remains unclear what the best energy source is to perform the surgery among prostate endoscopic enucleators. We sought to analyze studies that compared L-EEP and NL-EEP. There was no statistically significant difference in terms of functional outcomes. However, L-EEP was associated with a greater weight of resected tissue, but with no clinical significance. Surgical time, catheterization time, and length of hospital stay were similar in both groups. L-EEP was also associated with a lower decrease in Hb, but no differences were encountered in other complications.

Our study included only trials with level 1 evidence. However, our findings must be interpreted within the context of some limitations. First, the follow-up time was different among studies: only four studies [16, 17, 28, 31] had more than 5 years of follow-up, and most studies had a maximum follow-up of up to 12 months [8, 9, 11,12,13,14,15, 18, 19, 22,23,24,25,26, 32,33,34,35, 37, 39,40,41]. Therefore, the long-term efficacy and safety (beyond 5 years) comparing EEP and ENE cannot be evaluated due to lack of data. Second, there was high heterogeneity in the majority of the analysis, which could be explained by the heterogeneous population (with different inclusion criteria and different energy technologies for BPE treatment) included in each studied trial. Other aspects that may be emphasized are the impossibility of comparison according to preoperative prostate weight and the possible use of anticoagulants or antiplatelet therapies.

Conclusion

This study showed that EEP and ENE are both effective and safe for treating BPE. The majority of perioperative data favor EEP (lower Hb decrease, transfusion rate, catheterization time and length of hospital stay, but higher operation time and bladder injury rate). Besides statistical differences in functional outcomes and complication rates, the clinical significance of these findings is questionable. Compared with NL-EEP, L-EEP provides greater tissue removal and a smaller Hb decrease with the same functional profiles.

Long-term RCTs may provide an answer about whether EEP could replace ENE as the gold standard treatment for BPE.

References

  1. 1.

    Platz EA, Smit E, Curhan GC, Nyberg LM, Giovannucci E (2002) Prevalence of and racial/ethnic variation in lower urinary tract symptoms and noncancer prostate surgery in US men. Urology 59(6):877–883

    PubMed  Google Scholar 

  2. 2.

    Gravas S, Cornu JN, Drake MJ, Gacci M, Gratzke C, Herrmann TRW et al (2018) EAU Guidelines on Management of Non-Neurogenic Male Lower Urinary Tract Symptoms (LUTS), incl. Benign Prostatic Obstruction (BPO) 2018. European Association of Urology Guidelines 2018 Edition. presented at the EAU Annual Congress Copenhagen 2018. Arnhem, The Netherlands: European Association of Urology Guidelines Office

  3. 3.

    Gilling PJ, Kennett K, Das AK, Thompson D, Fraundorfer MR (1998) Holmium laser enucleation of the prostate (HoLEP) combined with transurethral tissue morcellation: an update on the early clinical experience. J Endourol 12(5):457–459

    CAS  PubMed  Google Scholar 

  4. 4.

    Foster HE, Barry MJ, Dahm P, Gandhi MC, Kaplan SA, Kohler TS et al (2018) Surgical management of lower urinary tract symptoms attributed to benign prostatic hyperplasia: AUA guideline. J Urol 200(3):612–619

    PubMed  Google Scholar 

  5. 5.

    Anderson B, Heiman J, Large T, Lingeman JE, Krambeck AE (2019) Trends and perioperative outcomes across Major BPH procedures from the ACS-NSQIP 2011–2015. J Endourol 33(1):62–68

    PubMed  Google Scholar 

  6. 6.

    Jadad AR, Moore RA, Carroll D, Jenkinson C, Reynolds DJ, Gavaghan DJ et al (1996) Assessing the quality of reports of randomized clinical trials: is blinding necessary? Control Clin Trials 17(1):1–12

    CAS  Google Scholar 

  7. 7.

    Ahyai SA, Lehrich K, Kuntz RM (2007) Holmium laser enucleation versus transurethral resection of the prostate: 3-year follow-up results of a randomized clinical trial. Eur Urol 52(5):1456–1463

    PubMed  Google Scholar 

  8. 8.

    Basić D, Stanković J, Potić M, Ignjatović I, Stojković I (2013) Holmium laser enucleation versus transurethral resection of the prostate: a comparison of clinical results. Acta Chir Iugosl 60(1):15–20

    PubMed  Google Scholar 

  9. 9.

    Bozzini G, Seveso M, Melegari S, de Francesco O, Buffi NM, Guazzoni G et al (2017) Thulium laser enucleation (ThuLEP) versus transurethral resection of the prostate in saline (TURis): a randomized prospective trial to compare intra and early postoperative outcomes. Actas Urol Esp 41(5):309–315

    CAS  PubMed  Google Scholar 

  10. 10.

    Chen YB, Chen Q, Wang Z, Peng YB, Ma LM, Zheng DC et al (2013) A prospective, randomized clinical trial comparing plasmakinetic resection of the prostate with holmium laser enucleation of the prostate based on a 2-year followup. J Urol 189(1):217–222

    PubMed  Google Scholar 

  11. 11.

    Elmansy H, Baazeem A, Kotb A, Badawy H, Riad E, Emran A et al (2012) Holmium laser enucleation versus photoselective vaporization for prostatic adenoma greater than 60 ml: preliminary results of a prospective, randomized clinical trial. J Urol 188(1):216–221

    PubMed  Google Scholar 

  12. 12.

    Eltabey MA, Sherif H, Hussein AA (2010) Holmium laser enucleation versus transurethral resection of the prostate. Can J Urol. 17(6):5447–5452

    PubMed  Google Scholar 

  13. 13.

    Fayad AS, Elsheikh MG, Zakaria T, Elfottoh HA, Alsergany R, Elshenoufy A et al (2015) Holmium laser enucleation of the prostate versus bipolar resection of the prostate: a prospective randomized study. “Pros and Cons”. Urology 86(5):1037–1041

    PubMed  Google Scholar 

  14. 14.

    Fayad AS, Sheikh MG, Zakaria T, Elfottoh HA, Alsergany R (2011) Holmium laser enucleation versus bipolar resection of the prostate: a prospective randomized study. Which to choose? J Endourol 25(8):1347–1352

    PubMed  Google Scholar 

  15. 15.

    Geavlete B, Bulai C, Ene C, Checherita I, Geavlete P (2015) Bipolar vaporization, resection, and enucleation versus open prostatectomy: optimal treatment alternatives in large prostate cases? J Endourol 29(3):323–331

    PubMed  Google Scholar 

  16. 16.

    Gilling PJ, Wilson LC, King CJ, Westenberg AM, Frampton CM, Fraundorfer MR (2012) Long-term results of a randomized trial comparing holmium laser enucleation of the prostate and transurethral resection of the prostate: results at 7 years. BJU Int 109(3):408–411

    PubMed  Google Scholar 

  17. 17.

    Gu M, Chen YB, Liu C, Wan X, Cai ZK, Chen Q et al (2018) Comparison of holmium laser enucleation and plasmakinetic resection of prostate: a randomized trial with 72-month follow-up. J Endourol 32(2):139–143

    PubMed  Google Scholar 

  18. 18.

    Gupta N, Sivaramakrishna Kumar R, Dogra PN, Seth A (2006) Comparison of standard transurethral resection, transurethral vapour resection and holmium laser enucleation of the prostate for managing benign prostatic hyperplasia of > 40 g. BJU Int 97(1):85–89

    PubMed  Google Scholar 

  19. 19.

    Hamouda A, Morsi G, Habib E, Hamouda H, Emam AB, Etafy M (2014) A comparative study between holmium laser enucleation of the prostate and transurethral resection of the prostate: 12-month follow-up. J Clin Urol 7(2):99–104

    Google Scholar 

  20. 20.

    Jhanwar A, Sinha RJ, Bansal A, Prakash G, Singh K, Singh V (2017) Outcomes of transurethral resection and holmium laser enucleation in more than 60 g of prostate: a prospective randomized study. Urol Ann 9(1):45–50

    PubMed  PubMed Central  Google Scholar 

  21. 21.

    Luo YH, Shen JH, Guan RY, Li H, Wang J (2014) Plasmakinetic enucleation of the prostate vs plasmakinetic resection of the prostate for benign prostatic hyperplasia: comparison of outcomes according to prostate size in 310 patients. Urology 84(4):904–910

    PubMed  Google Scholar 

  22. 22.

    Lusuardi L, Myatt A, Sieberer M, Jeschke S, Zimmermann R, Janetschek G (2011) Safety and efficacy of Eraser laser enucleation of the prostate: preliminary report. J Urol 186(5):1967–1971

    PubMed  Google Scholar 

  23. 23.

    Mavuduru RM, Mandal AK, Singh SK, Acharya N, Agarwal M, Garg S et al (2009) Comparison of HoLEP and TURP in terms of efficacy in the early postoperative period and perioperative morbidity. Urol Int 82(2):130–135

    CAS  PubMed  Google Scholar 

  24. 24.

    Montorsi F, Naspro R, Salonia A, Suardi N, Briganti A, Zanoni M et al (2008) Holmium laser enucleation versus transurethral resection of the prostate: results from a 2-center prospective randomized trial in patients with obstructive benign prostatic hyperplasia. J Urol 179(5 Suppl):S87–S90

    PubMed  Google Scholar 

  25. 25.

    Sun N, Fu Y, Tian T, Gao J, Wang Y, Wang S et al (2014) Holmium laser enucleation of the prostate versus transurethral resection of the prostate: a randomized clinical trial. Int Urol Nephrol 46(7):1277–1282

    PubMed  Google Scholar 

  26. 26.

    Swiniarski PP, Stepien S, Dudzic W, Kesy S, Blewniewski M, Rozanski W (2012) Thulium laser enucleation of the prostate (TmLEP) vs. transurethral resection of the prostate (TURP): evaluation of early results. Cent European J Urol 65(3):130–134

    PubMed  PubMed Central  Google Scholar 

  27. 27.

    Wilson LC, Gilling PJ, Williams A, Kennett KM, Frampton CM, Westenberg AM et al (2006) A randomised trial comparing holmium laser enucleation versus transurethral resection in the treatment of prostates larger than 40 grams: results at 2 years. Eur Urol 50(3):569–573

    PubMed  Google Scholar 

  28. 28.

    Yang Z, Liu T, Wang X (2016) Comparison of thulium laser enucleation and plasmakinetic resection of the prostate in a randomized prospective trial with 5-year follow-up. Lasers Med Sci 31(9):1797–1802

    PubMed  Google Scholar 

  29. 29.

    Zhang K, Sun D, Zhang H, Cao Q, Fu Q (2015) Plasmakinetic vapor enucleation of the prostate with button electrode versus plasmakinetic resection of the prostate for benign prostatic enlargement > 90 ml: perioperative and 3-month follow-up results of a prospective, randomized clinical trial. Urol Int 95(3):260–264

    PubMed  Google Scholar 

  30. 30.

    Zhao Z, Zeng G, Zhong W, Mai Z, Zeng S, Tao X (2010) A prospective, randomised trial comparing plasmakinetic enucleation to standard transurethral resection of the prostate for symptomatic benign prostatic hyperplasia: 3-year follow-up results. Eur Urol 58(5):752–758

    PubMed  Google Scholar 

  31. 31.

    Zhu L, Chen S, Yang S, Wu M, Ge R, Wu W et al (2013) Electrosurgical enucleation versus bipolar transurethral resection for prostates larger than 70 ml: a prospective, randomized trial with 5-year followup. J Urol 189(4):1427–1431

    PubMed  Google Scholar 

  32. 32.

    Feng L, Zhang D, Tian Y, Song J (2016) Thulium laser enucleation versus plasmakinetic enucleation of the prostate: a randomized trial of a single center. J Endourol 30(6):665–670

    PubMed  Google Scholar 

  33. 33.

    Wu G, Hong Z, Li C, Bian C, Huang S, Wu D (2016) A comparative study of diode laser and plasmakinetic in transurethral enucleation of the prostate for treating large volume benign prostatic hyperplasia: a randomized clinical trial with 12-month follow-up. Lasers Med Sci 31(4):599–604

    PubMed  Google Scholar 

  34. 34.

    Elshal AM, Elkoushy MA, El-Nahas AR, Shoma AM, Nabeeh A, Carrier S et al (2015) GreenLight laser (XPS) photoselective vapo-enucleation versus holmium laser enucleation of the prostate for the treatment of symptomatic benign prostatic hyperplasia: a randomized controlled study. J Urol 193(3):927–934

    PubMed  Google Scholar 

  35. 35.

    Kan CF, Tsu HL, Chiu Y, To HC, Sze B, Chan SW (2014) A prospective study comparing bipolar endoscopic enucleation of prostate with bipolar transurethral resection in saline for management of symptomatic benign prostate enlargement larger than 70 g in a matched cohort. Int Urol Nephrol 46(3):511–517

    PubMed  Google Scholar 

  36. 36.

    Li K, Wang D, Hu C, Mao Y, Li M, Si-Tu J et al (2018) A novel modification of transurethral enucleation and resection of the prostate in patients with prostate glands larger than 80 mL: surgical procedures and clinical outcomes. Urology 113:153–159

    PubMed  Google Scholar 

  37. 37.

    Mu XN, Wang SJ, Chen J, Jin XB, Huang ZX, Zhang LY (2017) Bipolar transurethral enucleation of prostate versus photoselective vaporization for symptomatic benign prostatic hyperplasia (> 70 ml). Asian J Androl 19(5):608–612

    CAS  PubMed  Google Scholar 

  38. 38.

    Ran L, He W, Zhu X, Zhou Q, Gou X (2013) Comparison of fluid absorption between transurethral enucleation and transurethral resection for benign prostate hyperplasia. Urol Int 91(1):26–30

    PubMed  Google Scholar 

  39. 39.

    Chang CH, Lin TP, Chang YH, Huang WJ, Lin AT, Chen KK (2015) Vapoenucleation of the prostate using a high-power thulium laser: a 1-year follow-up study. BMC Urol 15:40

    PubMed  PubMed Central  Google Scholar 

  40. 40.

    Neill MG, Gilling PJ, Kennett KM, Frampton CM, Westenberg AM, Fraundorfer MR et al (2006) Randomized trial comparing holmium laser enucleation of prostate with plasmakinetic enucleation of prostate for treatment of benign prostatic hyperplasia. Urology 68(5):1020–1024

    PubMed  Google Scholar 

  41. 41.

    Xu A, Zou Y, Li B, Liu C, Zheng S, Li H et al (2013) A randomized trial comparing diode laser enucleation of the prostate with plasmakinetic enucleation and resection of the prostate for the treatment of benign prostatic hyperplasia. J Endourol 27(10):1254–1260

    PubMed  Google Scholar 

  42. 42.

    Wroclawski ML, Carneiro A, Tristao RA, Sakuramoto PK, Youssef JD, Lopes Neto AC et al (2015) Giant prostatic hyperplasia: report of a previously asymptomatic man presenting with gross hematuria and hypovolemic shock. Einstein (Sao Paulo, Brazil) 13(3):420–422

    Google Scholar 

  43. 43.

    Rassweiler J, Teber D, Kuntz R, Hofmann R (2006) Complications of transurethral resection of the prostate (TURP)–incidence, management, and prevention. Eur Urol 50(5):969–979 (Discussion 80)

    PubMed  Google Scholar 

  44. 44.

    Carneiro A, Sakuramoto P, Wroclawski ML, Forseto PH, Den Julio A, Bautzer CR et al (2016) Open suprapubic versus retropubic prostatectomy in the treatment of benign prostatic hyperplasia during resident’s learning curve: a randomized controlled trial. Int Braz J Urol 42(2):284–292

    PubMed  PubMed Central  Google Scholar 

  45. 45.

    Jones P, Alzweri L, Rai BP, Somani BK, Bates C, Aboumarzouk OM (2016) Holmium laser enucleation versus simple prostatectomy for treating large prostates: results of a systematic review and meta-analysis. Arab J Urol 14(1):50–58

    PubMed  Google Scholar 

  46. 46.

    Cornu JN, Ahyai S, Bachmann A, de la Rosette J, Gilling P, Gratzke C et al (2015) A systematic review and meta-analysis of functional outcomes and complications following transurethral procedures for lower urinary tract symptoms resulting from benign prostatic obstruction: an update. Eur Urol 67(6):1066–1096

    PubMed  Google Scholar 

  47. 47.

    Qian X, Liu H, Xu D, Xu L, Huang F, He W et al (2017) Functional outcomes and complications following B-TURP versus HoLEP for the treatment of benign prostatic hyperplasia: a review of the literature and meta-analysis. Aging Male 20(3):184–191

    CAS  PubMed  Google Scholar 

  48. 48.

    Jiang H, Zhou Y (2016) Safety and efficacy of thulium laser prostatectomy versus transurethral resection of prostate for treatment of benign prostate hyperplasia: a meta-analysis. Low Urin Tract Symp 8(3):165–170

    CAS  Google Scholar 

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Wroclawski ML protocol/project development, data collection or management, data analysis, manuscript writing/editing. Teles SB protocol/project development, data collection or management, data analysis, manuscript writing/editing. Amaral BS protocol/project development, data collection or management, data analysis, manuscript writing/editing. Kayano PP protocol/project development, data collection or management, data analysis, manuscript writing/editing. Cha JD data collection or management, manuscript writing/editing. Carneiro A protocol/project development, manuscript writing/editing. Alfer Jr W manuscript writing/editing. Monteiro Jr J manuscript writing/editing. Gil AO manuscript writing/editing. Lemos GC manuscript writing/editing.

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Correspondence to Marcelo Langer Wroclawski.

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Wroclawski, M.L., Teles, S.B., Amaral, B.S. et al. A systematic review and meta-analysis of the safety and efficacy of endoscopic enucleation and non-enucleation procedures for benign prostatic enlargement. World J Urol 38, 1663–1684 (2020). https://doi.org/10.1007/s00345-019-02968-4

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Keywords

  • Endoscopic surgical procedures
  • Prostate
  • Outcomes assessments